EMERGENCY NUMBERS:

ACLS (for perioperative setting)

Fire – Airway .................................................. 12

Asystole

................................

............ 1 Fire – Patient .................................................. 13

Bradycardia

– Unstable .................... 2 Hemorrhage – MTG ...................................... 14

PEA

................................

................... 3 Hypotension .................................................. 15

SVT – Stable Tachycardia ................ 4 Hypoxemia .................................................... 16

SVT – Unstable Tachycardia ............ 5 Local Anesthetic Toxicity .............................. 17

VF/VT

................................

................ 6 Malignant Hyperthermia ................................ 18

Myocardial Ischemia ..................................... 19

BROAD DIFFERENTIAL DIAGNOSES

Oxygen Failure .............................................. 20

Hypotension

..................................... 15 PEA ............................................................... 3

Hypoxemia

....................................... 16 Pneumothorax ................................................ 21

Power Failure ................................................. 22

SPECIFIC CRITICAL EVENTS

SVT – Stable Tachycardia ............................. 4

Amniotic Fluid Embolism

................. 7 SVT – Unstable Tachycardia ......................... 5

Anaphylaxis

..................................... 8 Total Spinal Anesthesia ................................. 23

Asystole

................................

........... 1 Transfusion Reaction ..................................... 24

Bradycardia

– Unstable ................... 2 Venous Air Embolus ...................................... 25

Bronchospasm

................................. 9 VF/VT ............................................................. 6

Delayed Emergence

........................ 10 CRISIS RESOURCE MANAGEMENT .... 26

Difficult Airway

– Unanticipated ....... 11 Phone List ...................................................... 27

EMERGENCY MANUAL

COGNITIVE

AIDS FOR PERIOPERATIVE CRITICAL EVENTS 2016, V3.1

STANFORD ANESTHESIA COGNITIVE AID GROUP

To download free copy with CC licensing: HTTP://EMERGENCYMANUAL.STANFORD.EDU

To report adverse events & near misses: HTTP://WWW.AQIAIRS.ORG

EMERGENCY NUMBERS:

Hyperlinked PDF for mobile & digital navigation:

-To Jump to Events: Click Event Name

-To Return Here: Click Red Home button

This space

intentionally le blank

*Core Stanford Anesthesia Cognitive Aid Group contributors listed here in random order

Steve Howard, Larry Chu, Sara Goldhaber-Fiebert, David Gaba, Kyle Harrison

See http://emergencymanual.stanford.edu for latest updates, Creative Commons licensing BY-NC-ND

HOW THIS WORK CAME TO BE:

This Emergency Manual has a long history, evolving from decades of prior work on both Crisis Resource Management

(CRM) concepts and cognitive aids for critical incidents. The 1994 book entitled ‘Crisis Management in Anesthesiology’ by

Dr. David Gaba, Dr. Steven Howard, and Dr. Kevin Fish provided the initial foundations for this project. Their simulation

group has been involved in developing cognitive aids for operating rooms in the Palo Alto VA and then a national VA

project, each with bulleted points for many critical events. Observing that practitioners often miss key actions under stress,

Drs. Harrison and Goldhaber-Fiebert along with Dr. Geoff Lighthall, Dr. Ruth Fanning, Dr. Howard, and Dr. Gaba

developed several iterations of pocket cards for perioperative critical events, including some with rhythm strips, icons, and

color design. In 2004, Dr. Larry Chu conceived of adapting crisis management cognitive aids to a more visually striking

format for a new book he envisioned for today’s highly visual millennial learners. This became The Manual of Clinical

Anesthesiology, published in 2011. To create the current Emergency Manual, the Stanford Anesthesia Cognitive Aid

Group was formed. All team members have had integral roles. Dr. Larry Chu, who directs the Stanford AIM (Anesthesia

Informatics Management) lab provided the new graphics and layout, applying his design skills and an understanding of

user interface to make the content more easily usable. Drs. Sara Goldhaber-Fiebert, Kyle Harrison, Steven Howard, and

David Gaba worked jointly to provide the content, including exact phrasing, ordering, and emphasis, as well as iterative

simulation testing to revise both content and design elements. Observing how cognitive aids are used by teams during

hundreds of simulated crises has been crucial for pilot testing throughout. We hope that this Emergency Manual will

support both education and patient safety efforts. Effective use has included pre-event review, post-event team debriefing,

and ‘during’ critical event management—the latter particularly after adequate help has arrived or when the patient is

sufficiently stable for a clinician to pause from acute care actions. We encourage the use of this Manual and welcome

feedback from all practitioners.

Acknowledgments: We appreciate the faculty and residents at Stanford and VA Palo Alto anesthesia departments for

their support of the development and implementation of the emergency manual. We are especially grateful to our chair,

Dr. Ron Pearl, for helping us make this project a reality. We are grateful to Barbara Burian for her expertise in human

factors and cognitive aid design reflected in the design of Version 3. While references are not written on each event for

space, we have tried to integrate the most pertinent clinical information from published literature for each event, including

practical publications e.g. A-ACLS modifications to AHA ACLS algorithms, ASA difficult airway algorithms, ASRA LAST

guidelines, MHAUS poster, and appreciate the work of their developers. We thank all our colleagues from the Emergency

Manuals Implementation Collaborative (EMIC), a global group fostering the dissemination, implementation, and effective

use of emergency manuals to enhance patients’ safety. Join EMIC at www.emergencymanuals.org.

Disclaimer: The material in this Manual is not intended to be a substitute for sound medical knowledge and training.

Clinicians should always use their clinical judgment and decision making for patient management. Since treatment for the

medical conditions described in this Manual can have variable presentations, departure from the information presented

here is encouraged when appropriate.

APPROPRIATE CITATION OF THIS EMERGENCY MANUAL

Stanford Anesthesia Cognitive Aid Group*. Emergency Manual: Cognitive aids for perioperative clinical events. See

http://emergencymanual.stanford.edu for latest version. Creative Commons BY-NC-ND. 2013 (creative

commons.org/licenses/by-nc-nd/3.0/legalcode). *Core contributors in random order: Howard SK, Chu LK, Goldhaber-

Fiebert SN, Gaba DM, Harrison TK.

MANUAL OF CLINICAL ANESTHESIOLOGY

Much of the work in this Anesthesia Emergency Manual was adapted from cognitive aids originally published in Appendix

of Crisis Management Algorithms in Anesthesia in the Manual of Clinical Anesthesiology, edited by Larry Chu and Andrea

Fuller, published by Lippincott Williams & Wilkins, 2011. The authors were*: Harrison TK (21), Goldhaber-Fiebert SN (21),

and Chu L (21), as well as on specific cognitive aids, contributions by: Lighthall G (2),

PRODUCED BY THE STANFORD ANESTHESIA

INFORMATICS AND MEDIA LAB (AIM)

HTTP://AIM.STANFORD.EDU

TESTED BY THE STANFORD SIMULATION GROUP

AND THE STANFORD ANESTHESIA INFORMATICS

AND MEDIA (AIM) LAB

ASYSTOLE

By Stanford Anesthesia Cognitive Aid Group

SIGNS

FLAT LINE:

PULSE



CPR:

1. 100–120 compressions/minute;

≥ 2”

deep.

Allow complete chest recoil.

Minimize breaks

in CPR.

3. Rotate Compressors q2 Min.

Assess CPR quality, improve IF:

• ETCO

< 10 mmHg

• Arterial line Diastolic < 20 mmHg

1. CALL FOR HELP.

2. CALL FOR CODE CART.

3. INFORM TEAM.

IMMEDIATE

1. Turn OFF vasodilating volatile & IV drips; Increase to 100% O

, high flow.

2. Ventilate 10 breaths/minute; do not over ventilate.

3. Ensure IV access (or consider intraosseous).

4. Epinephrine – 1 mg IV push q 3-5 minutes.

5. If rhythm changes to VF/VT (shockable rhythm)



Immediate Defibrillation.

Go To VF/VT, event #6.

6. Consider ECMO if available and reversible cause.

7. Consider TTE or TEE Echocardiography to evaluate cause.

Emergency Manual V3.0 Aug. 2016

DIAGNOSIS

Consider common perioperative Ddx:

1. Hemorrhage

2. Anesthetic overdose

3. Septic or other shock states

4. Auto PEEP

5. Anaphylaxis

6. Medication error

7. High spinal

8. Pneumothorax

9. Local anesthetic toxicity

10. Vagal stimulus

11. Pulmonary Embolus

Find and Treat Causes – H’s and T’s: Expanded on next page.

Go To Next Page è

Emergency Manual V3.0 2016

ASYSTOLE

continued

DETAILS

1. Hypovolemia: Give rapid bolus of IV fluid. Check hemoglobin/hematocrit. If

anemia or massive hemorrhage, give blood. Consider relative hypovolemia:

Auto-PEEP (disconnect circuit); High Spinal; or Shock States (e.g.

anaphylaxis). Go To relevant event.

2. Hypoxemia: Increase O

, to 100% high flow. Confirm connections. Check for

bilateral breath sounds. Suction ET tube and reconfirm placement. Consider

chest X-ray. Go To Hypoxemia, event #16.

3. Tension pneumothorax: Unilateral breath sounds, possible distended neck

veins and deviated trachea (late signs). Perform emergent needle

decompression (2

intercostal space at mid-clavicular line) then chest tube

placement. Call for chest x-ray, but do NOT delay treatment. Go To

Pneumothorax, event #21.

4. Thrombosis – Coronary: Consider transesophageal (TEE) or transthoracic

(TTE) echocardiography to evaluate ventricle wall motion abnormalities of the

ventricles. Consider emergent coronary revascularization. Go To Myocardial

Ischemia, event #19.

5. Thrombosis – Pulmonary: Consider TEE or TTE to evaluate right ventricle.

Consider fibrinolytic agents or pulmonary thrombectomy.

6. Toxins (e.g. infusions): Consider medication error. Confirm no infusions

running and volatile anesthetic off. If local anesthetic toxicity Go To Local

Anesthetic Toxicity, event #17.

7. Tamponade – Cardiac: Consider placing TEE or TTE to rule out tamponade.

Treat with pericardiocentesis.

8. Hypothermia ê: Active warming by forced air blanket, warm IV fluid, raise

room temperature. Consider cardiopulmonary bypass.

9. Hyperthermia é: If Malignant Hyperthermia, call for MH Cart. Give

Dantrolene immediately: start at 2.5 mg/kg. MH Hotline: (800) 644-9737.

Go To Malignant Hyperthermia, event #18.

10. Obtain ABG to rule out:

• Hyperkalemia é: Give Calcium Chloride 1 g IV; D50 1 Amp IV

(25 g Dextrose) + Regular Insulin 10 units IV. Monitor glucose.

Sodium Bicarbonate 1 Amp IV (50 mEq).

• Hypokalemia ê: Controlled infusion of potassium & magnesium.

• Hypoglycemia: If ABG delay, check Fingerstick. Give D50 1 Amp IV

(25 g Dextrose). Monitor glucose.

• H+ Acidosis: If profound, consider Sodium Bicarbonate 1 Amp IV

(50 mEq). May consider increasing ventilation rate (but can decrease

CPR effectiveness so monitor).

• Hypocalcemia: Give Calcium Chloride 1 g IV.

Emergency Manual V3.0 Aug. 2016

END

 

Emergency Manual V3.0 2016

BRADYCARDIA – UNSTABLE

By Stanford Anesthesia Cognitive Aid Group

SIGNS

1. CHECK FOR PULSE

• If NO pulse, Go To PEA event #3.

• If pulse present but hypotensive, proceed with treatment.

1. CALL FOR HELP.

2. CALL FOR CODE CART.

3. HALT SURGICAL STIMULATION.



TREATMENT

1. Increase to 100% O

, high flow.

2. Confirm adequate ventilation and oxygenation.

3. Consider turning down or OFF all anesthetics.

4. Atropine: 0.5 to 1 mg IV, may repeat up to 3 mg.

Consider infusions below.

5. Consider transcutaneous pacing:

é • Set rate to at least 80 bpm.

OR • Increase current until capture achieved.

ê • Confirm patient has pulse with capture.

6. Consider Infusions:

• Dopamine: 2 to 20 μg/kg/min

• Epinephrine: 2 to 10 μg/min

SECONDARY

1. Place arterial line.

2. Send labs: ABG, hemoglobin, electrolytes.

3. Rule out ischemia: Consider EKG, troponins.

Emergency Manual V3.0 Aug. 2016

END

 

Emergency Manual V3.0 2016

PULSELESS ELECTRICAL ACTIVITY

By Stanford Anesthesia Cognitive Aid Group

SIGNS





PULSE



CPR:

1. 100–120 compressions/minute;

≥ 2” deep.

Allow complete chest recoil.

2. Minimize breaks in CPR.

3. Rotate Compressors q2 Min.

Assess CPR quality, improve IF:

• ETCO

< 10 mmHg

• Arterial line Diastolic < 20 mmHg

1. CALL FOR HELP.

2. CALL FOR CODE CART.

3. INFORM TEAM.

IMMEDIATE

1. Turn OFF vasodilating volatile & IV drips; Increase to 100% O

, high flow.

2. Ventilate 10 breaths/minute; do not over ventilate.

3. Ensure IV access (or consider intraosseous).

4. Epinephrine – 1 mg IV push q 3-5 minutes.

5. If rhythm changes to VF/VT (shockable rhythm)  Immediate Defibrillation.

Go To VF/VT, event #6.

6. Consider ECMO if available and reversible cause.

7. Consider TTE or TEE Echocardiography to evaluate cause.

Emergency Manual V3.0 Aug. 2016

SECONDARY

Consider common perioperative Ddx:

1. Hemorrhage

2. Anesthetic overdose

3. Septic or other shock states

4. Auto PEEP

5. Anaphylaxis

6. Medication error

7. High spinal

8. Pneumothorax

9. Local anesthetic toxicity

10. Vagal stimulus

11. Pulmonary Embolus

Find and Treat Causes – H’s and T’s: Expanded on next page.

Go To Next Page è

 

Emergency Manual V3.0 2016

PULSELESS ELECTRICAL ACTIVITY continued

DETAILS

1. Hypovolemia: Give rapid bolus of IV fluid. Check hemoglobin/hematocrit. If

anemia or massive hemorrhage, give blood. Consider relative hypovolemia:

Auto-PEEP (disconnect circuit); High Spinal; or Shock States (e.g.

anaphylaxis). Go To relevant event.

2. Hypoxemia: Increase O

, to 100% high flow. Confirm connections. Check for

bilateral breath sounds. Suction ET tube and reconfirm placement. Consider

chest X-ray. Go To Hypoxemia, event #16.

3. Tension pneumothorax: Unilateral breath sounds, possible distended neck

veins and deviated trachea (late signs). Perform emergent needle

decompression (2

intercostal space at mid-clavicular line) then chest tube

placement. Call for chest x-ray, but do NOT delay treatment. Go To

Pneumothorax, event #21.

4. Thrombosis – Coronary: Consider transesophageal (TEE) or transthoracic

(TTE) echocardiography to evaluate ventricle wall motion abnormalities of the

ventricles. Consider emergent coronary revascularization. Go To Myocardial

Ischemia, event #19.

5. Thrombosis – Pulmonary: Consider TEE or TTE to evaluate right ventricle.

Consider fibrinolytic agents or pulmonary thrombectomy.

6. Toxins (e.g. infusions): Consider medication error. Confirm no infusions

running and volatile anesthetic off. If local anesthetic toxicity Go To Local

Anesthetic Toxicity, event #17.

7. Tamponade – Cardiac: Consider placing TEE or TTE to rule out tamponade.

Treat with pericardiocentesis.

8. Hypothermia ê: Active warming by forced air blanket, warm IV fluid, raise

room temperature. Consider cardiopulmonary bypass.

9. Hyperthermia é: If Malignant Hyperthermia, call for MH Cart. Give

Dantrolene immediately: start at 2.5 mg/kg. MH Hotline: (800) 644-9737.

Go To Malignant Hyperthermia, event #18.

10. Obtain ABG to rule-out:

• Hyperkalemia é: Give Calcium Chloride 1 g IV; D50 1 Amp IV

(25 g Dextrose) + Regular Insulin 10 units IV. Monitor glucose.

Sodium Bicarbonate 1 Amp IV (50 mEq).

• Hypokalemia ê: Controlled infusion of potassium & magnesium.

• Hypoglycemia: If ABG delay, check Fingerstick. Give D50 1 Amp IV

(25 g Dextrose). Monitor glucose.

• H+ Acidosis: If profound, consider Sodium Bicarbonate 1 Amp IV

(50 mEq). May consider increasing ventilation rate (but can decrease

CPR effectiveness so monitor).

• Hypocalcemia: Give Calcium Chloride 1 g IV.

Emergency Manual V3.0 Aug. 2016

END

 

Emergency Manual V3.0 2016

SUPRAVENTRICULAR TACHYCARDIA –

STABLE

By Stanford Anesthesia Cognitive Aid Group

SIGNS

1. CHECK FOR PULSE.

• If NO pulse, Go To PEA, event #3.

• If Unstable, Go To SVT – UNSTABLE event #5.

Prepare for Synchronized Cardioversion.

UNSTABLE = ANY OF: Sudden and/or continuing sharp

decrease in BP; Acute Ischemia; SBP <75.

2. Sinus Tachycardia is NOT SVT. May be compensatory. Search for

and treat underlying cause(s).

3. More likely SVT THAN SINUS if any of:

• Rate >150.

• Irregular.

• Sudden onset.

1. CALL FOR HELP.

2. CALL FOR CODE CART?

3. INFORM TEAM.

Emergency Manual V3.0 Aug. 2016

IMMEDIATE

1. Increase to 100% O

, high flow.

2. Confirm adequate ventilation, oxygenation.

3. Consider 12-lead EKG or Print Rhythm Strip, then treat per

rhythm (Go To next page).

4. If UNSTABLE at any point: Go To SVT – UNSTABLE, event #5.

5. Consider placing defibrillator pads.

5. If still STABLE Supraventricular Tachycardia consider:

• arterial line.

• check ABG & electrolytes.

7. Consider STAT cardiology consult.

8. Go To next page.

Go To Next Page è

 

Emergency Manual V3.0 2016

SUPRAVENTRICULAR TACHYCARDIA – STABLE

continued

Narrow Complex and Regular

1. Adenosine 6 mg IV push with flush. May give 2

dose: 12 mg IV

(Avoid adenosine if asthma or WPW).

2. If NOT converted, may Rate Control.

Choose beta blocker or calcium channel blocker:

• Beta Blocker: (consider avoiding if asthma)

- Esmolol: Start 0.5 mg/kg IV over 1 min. May repeat after 1

min and may start infusion 50 μg/kg/min.

- Metoprolol: Start 1-2.5 mg IV. May repeat or double after

2.5 min.

• Calcium Channel Blocker:

- Diltiazem: 5-10 mg IV over 2 min. May repeat after 5 min.

Narrow Complex and Irregular

1. Choose beta blocker or calcium channel blocker:

• Beta Blocker: (Consider avoiding if asthma)

- Esmolol: Start 0.5 mg/kg IV over 1 min. May repeat after 1

min and may start infusion 50 μg/kg/min.

- Metoprolol: Start 1-2.5 mg IV. May repeat or double after 2.5

min.

• Calcium Channel Blocker:

- Diltiazem: 5-10 mg IV over 2 min. May repeat after 5 min.

2. Amiodarone: 150 mg IV SLOWLY over 10 min. May repeat once.

Start infusion 1 mg/min for first 6 hours.

Wide Complex and Regular (monomorphic)

1. If SVT with aberrancy Adenosine: 6 mg IV push with flush. May

give 2nd dose: 12 mg IV (avoid adenosine if asthma or WPW).

2. If VT or uncertain VT versus SVT with aberrancy:

Amiodarone: 150 mg IV SLOWLY over 10 min. May repeat once.

Start infusion 1 mg/min for first 6 hours.

May also consider Procainamide or Sotalol.

Emergency Manual V3.0 Aug. 2016

Wide Complex and Irregular

(Likely Polymorphic VT)

If Unstable, immediate defibrillation.

If Stable, have defibrillator pads on and consult cardiology.

END

 

Emergency Manual V3.0 2016

SUPRAVENTRICULAR TACHYCARDIA –

UNSTABLE

By Stanford Anesthesia Cognitive Aid Group

SIGNS

1. CHECK FOR PULSE.

• If NO pulse, Go To PEA, event #3.

2. UNSTABLE

= ANY OF: Sudden and/or continuing sharp decrease

in BP; Acute Ischemia; SBP <75.

3. Sinus Tachycardia is NOT SVT

. May be compensatory. Search for

and treat underlying cause(s).

4. More likely SVT THAN SINUS if any of:

• Rate >150.

• Irregular.

• Sudden onset.

1. CALL FOR HELP.

2. CALL FOR CODE CART.

3. INFORM TEAM.



TREATMENT

1. Increase to 100% O

, high flow. Decrease volatile anesthetic.

2. Confirm adequate ventilation, oxygenation.

3. If unstable SVT, IMMEDIATE SYNCHRONIZED

CARDIOVERSION – biphasic doses.

• Narrow complex and Regular: 50-100J.

• Narrow complex and Irregular: 120-200J.

• Wide complex and Regular: 100J.

• Wide complex and Irregular requires Unsynchronized

Defibrillation: 200J.

4. If unsuccessful cardioversion: Re-SYNC and increase Joules

incrementally for Synchronized Cardioversion.

5. While preparing to cardiovert (do NOT delay), if narrow-complex

and regular, consider Adenosine 6 mg rapid IV push with flush,

via access closest to heart. May give 2nd dose of 12 mg IV.

Emergency Manual V3.0 Aug. 2016

END

 

Emergency Manual V3.0 2016

VENTRICULAR FIBRILLATION

VENTRICULAR TACHYCARDIA – PULSELESS

By Stanford Anesthesia Cognitive Aid Group

SIGNS

V-TACH:

V-FIB:

CPR:

1. 100–120 compressions/minute;

≥ 2” deep.

Allow complete chest recoil.

2. Minimize breaks in CPR.

3. Rotate compressors q2 min.



Assess CPR quality, improve IF:

• ETCO

< 10 mmHg.

• Arterial line Diastolic < 20 mmHg.

1. CALL FOR HELP.

2. CALL FOR CODE CART.

3. INFORM TEAM.

TREATMENT

1. DEFIBRILLATE: 120-200 J (biphasic, per manufacturer).

2. RESUME CPR IMMEDIATELY.

3. REPEAT SHOCK q 2 minutes, reasonable to increase energy

with subsequent shocks, resume CPR.

4. AFTER 2

SHOCK EPINEPHRINE: 1 mg IV push q 3-5 minutes.

CHECK

1. In OR: Turn OFF volatile; Increase to 100% O

, high flow.

2. Ventilate 10 breaths/minute; do not overventilate.

3. Ensure IV access (or consider intraosseous).

Emergency Manual V3.0 Aug. 2016

CONSIDER

Consider Antiarrhythmics:

• If pulseless: Amiodarone 300 mg IV PUSH or Lidocaine 100 mg

IV PUSH.

• If HypoMg or Torsades + prolonged QT: Magnesium sulfate 2

grams IV.

• If HyperK: Calcium, insulin & glucose, sodium bicarbonate.

Search for Treatable Causes (H’s & T’s on next page).

Go To Next Page è

 

Emergency Manual V3.0 2016



VENTRICULAR FIBRILLATION

VENTRICULAR TACHYCARDIA – PULSELESS

continued

If still VF/VT, keep shocking q2 minutes.

DETAILS

1. Hypovolemia: Give rapid bolus of IV fluid. Check hemoglobin/hematocrit. If

anemia or massive hemorrhage, give blood. Consider relative hypovolemia:

Auto-PEEP (disconnect circuit); High Spinal; or Shock States (e.g.

anaphylaxis). Go To relevant event.

2. Hypoxemia: Increase O

, to 100% high flow. Confirm connections. Check for

bilateral breath sounds. Suction ET tube and reconfirm placement. Consider

chest X-ray. Go To Hypoxemia, event #16.

3. Tension pneumothorax: Unilateral breath sounds, possible distended neck

veins and deviated trachea (late signs). Perform emergent needle

decompression (2

intercostal space at mid-clavicular line) then chest tube

placement. Call for chest x-ray, but do NOT delay treatment. Go To

Pneumothorax, event #21.

4. Thrombosis – Coronary: Consider transesophageal (TEE) or transthoracic

(TTE) echocardiography to evaluate ventricle wall motion abnormalities of the

ventricles. Consider emergent coronary revascularization. Go To Myocardial

Ischemia, event #19.

5. Thrombosis – Pulmonary: Consider TEE or TTE to evaluate right ventricle.

Consider fibrinolytic agents or pulmonary thrombectomy.

6. Toxins (e.g. infusions): Consider medication error. Confirm no infusions

running and volatile anesthetic off. If local anesthetic toxicity Go To Local

Anesthetic Toxicity, event #17.

7. Tamponade – Cardiac: Consider placing TEE or TTE to rule out tamponade.

Treat with pericardiocentesis.

8. Hypothermia ê: Active warming by forced air blanket, warm IV fluid, raise

room temperature. Consider cardiopulmonary bypass.

9. Hyperthermia é: If Malignant Hyperthermia, call for MH Cart. Give

Dantrolene immediately: start at 2.5 mg/kg. MH Hotline: (800) 644-9737.

Go To Malignant Hyperthermia, event #18.

10. Obtain ABG to rule-out:

• Hyperkalemia é: Give Calcium Chloride 1 g IV; D50 1 Amp IV

(25 g Dextrose) + Regular Insulin 10 units IV. Monitor glucose.

Sodium Bicarbonate 1 Amp IV (50 mEq).

• Hypokalemia ê: Controlled infusion of potassium & magnesium.

• Hypoglycemia: If ABG delay, check Fingerstick. Give D50 1 Amp IV

(25 g Dextrose). Monitor glucose.

• H+ Acidosis: If profound, consider Sodium Bicarbonate 1 Amp IV

(50 mEq). May consider increasing ventilation rate (but can decrease

CPR effectiveness so monitor).

• Hypocalcemia: Give Calcium Chloride 1 g IV.

Emergency Manual V3.0 Aug. 2016

If still VF/VT, keep shocking q2 minutes.

END

 

Emergency Manual V3.0 2016

AMNIOTIC FLUID EMBOLISM

By Stanford Anesthesia Cognitive Aid Group

SIGNS

Consider amniotic fluid embolism if there is the sudden onset of

the following in a pregnant or post-partum patient:

1. Respiratory distress, decreased O

saturation.

2. Cardiovascular collapse: hypotension, tachycardia,

arrhythmias, cardiac arrest.

3. Coagulopathy +/- Disseminated intravascular coagulation

(DIC).

4. Seizures.

5. Altered mental status.

6. Unexplained fetal compromise.

1. CALL FOR HELP.

2. CALL FOR CODE CART.

3. INFORM TEAM.

TREATMENT

1. Anticipate possible cardiopulmonary arrest and emergent

C-section.

2. Place patient in left uterine displacement (LUD).

3. Increase to 100% O

, high flow.

4. Establish large volume IV access (upper body best).

5. Support circulation with IV fluid, vasopressors, and

inotropes.

6. Prepare for emergent intubation.

7. When possible, place arterial line. Consider central venous

access or IO line in humerus.

8. Anticipate massive hemorrhage and DIC. Go To

Hemorrhage – MTG, event #14.

9. Consider circulatory support: IABP/ECMO/CPB.

Emergency Manual V3.0 Aug. 2016

RULE OUT

Rule out other causes that might present in a similar fashion:

1. Eclampsia. 7. Anesthetic overdose.

2. Hemorrhage. 8. Sepsis.

3. Air embolism. 9. Cardiomyopathy/cardiac valvular

4. Aspiration. abnormality/MI.

5. Anaphylaxis. 10. Local anesthetic toxicity.

6. Pulmonary embolism. 11. Total Spinal.

END

 

Emergency Manual V3.0 2016

ANAPHYLAXIS

By Stanford Anesthesia Cognitive Aid Group

SIGNS

Some signs may be absent in an anesthetized patient:

1. Hypoxemia, difficulty breathing, tachypnea.

2. Rash/hives.

3. Hypotension (may be severe).

4. Tachycardia.

5. Bronchospasm/wheezing.

6. Increase in peak inspiratory pressure (PIP).

7. Angioedema (potential airway swelling).

1. CALL FOR HELP.

2. CALL FOR CODE CART.

3. INFORM TEAM.

4. CONSIDER PAUSING SURGERY.

1. If patient becomes pulseless, start CPR, continue

epinephrine 1 mg IV boluses and large volume IV fluid.

2. Also Go To PEA, event #3.

Emergency Manual V3.0 Aug. 2016

RULE OUT

Consider and rule out other causes:

• Pulmonary embolus. • Pneumothorax.

• Myocardial infarction. • Hemorrhage.

• Anesthetic overdose. • Aspiration.

For anaphylaxis treatment, Go To Next Page è

 

Emergency Manual V3.0 2016

ANAPHYLAXIS continued

TREATMENT

1. Discontinue potential allergens: muscle relaxants, latex,

antibiotics, colloids, protamine, blood, contrast, chlorhexidine.

2. Discontinue volatile anesthetic if hypotensive. Consider

amnestic agent.

3. Increase to 100% O

, high flow.

4. Give IV fluid bolus. May require many liters!

5. Give epinephrine IV in escalating doses every two minutes.

Start at 10-100 μg IV and increase dose every 2 minutes until

clinical improvement is noted. Start early epinephrine

infusion. May require large doses > 1 mg.

6. IF no improvement: continue treatment, but consider other

causes (Go To Hypotension, event #15, and Hypoxemia,

event #16 – consider Differential Diagnoses).

7. Consider vasopressin bolus IV or norepinephrine infusion.

8.Treat bronchospasm with albuterol and epinephrine (if

severe).

9. Consider additional IV access and invasive monitors (arterial

line).

10. If signs of angioedema, consider early intubation to secure

airway.

11. After stable consider H

antagonist (e.g. Diphenhydramine 25-

50 mg IV),H

antagonist (e.g. Ranitidine 50 mg IV), and

corticosteroids (e.g. Methylprednisolone 125 mg IV).

POST EVENT

Consider the following interventions when patient stable:

1. Send serum tryptase level (peaks <60 min post-event).

2. Send serum histamine (peaks <30 min post-event).

3. If the event was severe, consider keeping patient intubated

and sedated.

4. Can recur after initial treatment: Consider monitoring patient for

24 hours post-recovery.

5. Refer the patient for postoperative allergy testing.

Emergency Manual V3.0 Aug. 2016

END

 

Emergency Manual V3.0 2016

BRONCHOSPASM

(INTUBATED PATIENT)

By Stanford Anesthesia Cognitive Aid Group

SIGNS

1. Increased peak airway

pressures.

2. Wheezing on lung exam.

3. Increased expiratory time.

4. Increased ETCO

with

upsloping ETCO

waveform.

5. Decreased tidal volumes if pressure control.

1. CALL FOR HELP.

2. CALL FOR CODE CART?

3. INFORM TEAM.



Bronchospastic patients who develop sudden

hypotension may be airtrapping – disconnect

patient from circuit to allow for complete

exhalation.

TREATMENT

1. Increase to 100% O

, high flow.

2. Change I:E ratio to allow for adequate exhalation.

3. Deepen anesthetic (sevoflurane or propofol).

4. Rule out problems with ETT via auscultation & suction

catheter (mainstem intubation, kinked ETT, mucus plug) .

5. Give inhaled agents: Beta 2 agonist (albuterol, multiple puffs

required) +/- anticholinergic (Ipratropium).

6. If severe consider epinephrine (start with 10 μg IV and

escalate, monitor for tachycardia and hypertension).

7. Consider ketamine: 0.2 – 1.0 mg/kg IV.

8. Consider hydrocortisone 100 mg IV.

9. Consider nebulized racemic epinephrine.

10. Rule out anaphylaxis (hypotension/tachycardia/rash). Go To

Anaphylaxis, event #8.

11. Consider ABG.

Emergency Manual V3.0 Aug. 2016

END

 

Emergency Manual V3.0 2016

DELAYED EMERGENCE

By Stanford Anesthesia Cognitive Aid Group

CHECK

1. Confirm that all anesthetic agents (inhalation/IV) are OFF.

2. Check for residual muscular paralysis (if patient is asleep, use

twitch monitor), and reverse accordingly.

CONSIDER

Consider:

1. Opioid reversal: start with naloxone 40 μg IV; repeat every 2

minutes, increasing up to 400 μg.

2. Benzodiazepine reversal: start with flumazenil 0.2 mg IV every

1 minute; max dose = 1 mg.

3. Scopolomine reversal (e.g. Patch): Physostigmine 1 mg IV

(Potential cholinergic crisis, including severe bradycardia, so have

atropine ready).

CHECK

1. Monitors: Check Hypoxemia? Hypercarbia? Hypothermia?

2. Complete Neuro exam, as able, for focal neurologic deficits (if

intubated look for: pupils, asymmetric movement, gagging, etc.)

If abnormal exam or suspect stroke, obtain stat Head CT scan

and consult neurology/neurosurgery.

3. Hypoglycemia: check glucose (glucometer).

4. Labs: ABG plus electrolytes. Rule out CO

narcosis from

Hypercarbia, Hypo- or Hypernatremia.

5. Check for medication swap or dosing error.

TREATMENT

1. Correct any abnormalities in oxygenation, ventilation, laboratory

values, or temperature.

2. If residual mental status abnormalities, monitor the patient in the

ICU with neurological follow up, including serial exams. Repeat

Head CT or MRI as needed.

Emergency Manual V3.0 Aug. 2016

END

 

Emergency Manual V3.0 2016

DIFFICULT AIRWAY

UNANTICIPATED

By Stanford Anesthesia Cognitive Aid Group and Vladimir Nekhendzy, MD

If unable to see vocal cords or pass ET tube during first Direct

Laryngoscopy (DL):

1. Consider External Laryngeal Manipulation, BURP (Backwards Upwards

Rightwards Pressure).

2. Consider placing Bougie introducer.

3. Limit total number of DL attempts to 2.

4. Recommend Video Assisted Laryngoscopy.

5. Before repeating DL, consider mask ventilation with oral/nasal airways.

6. Consider optimizing patient position and/or blade selection.

7. If successful, confirm placement with ETCO

and bilateral breath sounds.

Can NOT

Intubate

1. Attempt face mask ventilation – consider oral airway.

2. Call for Difficult Airway cart.

Can NOT Successful

Ventilate Ventilation

CALL FOR HELP!

Place oral, nasal airway

switch to two-handed

mask ventilation.

If at any point inadequate

ventilation by mask or LMA,

Go To Red Box.

Can NOT

Ventilate

If ventilation remains adequate,

CONSIDER:

1. Awakening patient.

2. Complete case with LMA or

face mask.

3. Video assisted Laryngoscopy.

4. Asleep fiberoptic

bronchosocopy.

5. LMA as conduit for intubation

or intubating LMA.

6. Retrograde wire intubation.

1. Place LMA if feasible.

2. Consider any SGA,

Intubating LMA,

Combitube, or

Laryngeal Tube.

Successful

Ventilation

Emergency Manual V3.0 Aug. 2016

Can NOT

Ventilate

Emergency Airway Ventilation

1. Call for Surgical Help.

2. Perform Cricothyrotomy.

3. Confirm successful placement with ETCO

and bilateral breath sounds.

For more details, see latest ASA Practice Guidelines for the Management of Difficult

Airway

END

 

Emergency Manual V3.0 2016

FIRE – AIRWAY

FOR NON-AIRWAY FIRE: Go To Fire – Patient, event #13

By Stanford Head & Neck Anesthesia & Surgery, Stanford Anesthesia Cognitive Aid Group

SIGNS

SUSPECT FIRE if:

Sudden pop, spark, flame, smoke, heat, or odor.

1. CALL FOR HELP.

2. INFORM TEAM.

Emergency Manual V3.0 Aug. 2016

IMMEDIATE

SURGEON:

1. REMOVE ENDOTRACHEAL TUBE.

2. Remove airway foreign bodies e.g. ETT pieces.

3. Pour saline or water into patient’s airway.

4. Examine entire airway (including bronchoscopy) to assess injury

and remove residual debris.

ANESTHESIOLOGIST:

1. STOP ALL AIRWAY GAS FLOW BY DISCONNECTING THE

BREATHING CIRCUIT FROM THE ANESTHESIA MACHINE.

2. When sure fire is extinguished: Re-establish ventilation; avoid

supplemental O

if possible .

3. Consider prompt reintubation prior to swelling and coordinated

with surgeon’s bronchoscopy.

4. Inspect ETT pieces to verify none left in airway.

5. Save all materials for later investigation.

For prevention of airway fires, see next page.

GO TO NEXT PAGE è

 

Emergency Manual V3.0 2016

FIRE – AIRWAY continued

FOR NON-AIRWAY FIRE: Go To Fire – Patient, event #13

PREVENTION

If high risk procedures, including those listed below:

• Discuss fire prevention & management with team

during time-out.

• Avoid FiO

> 0.3 and avoid N

For laser surgery of vocal cord or larynx:

• Use laser resistant ETT (single or double cuff).

• Assure ETT cuff sufficiently deep below vocal cords.

• Fill proximal ETT cuff with methylene blue-tinted saline.

• Ensure Laser in STANDBY when not in active use.

• Surgeon protects ETT cuff with WET gauze.

• Surgeon confirms FiO

< 0.3 and no N

O prior to laser

use.

For non-laser surgery in oropharynx:

• Regular PVC ETT may be used.

• Consider packing wet gauze around ETT to minimize

leakage.

• Consider continuous suctioning of the operating field

inside oropharynx.

Emergency Manual V3.0 Aug. 2016

END

 

Emergency Manual V3.0 2016

FIRE – PATIENT

FOR AIRWAY FIRE: Go To Fire – Airway, event #12

By Stanford Anesthesia Cognitive Aid Group, Stanford Head & Neck Anesthesia & Surgery

SIGNS

SUSPECT FIRE if:

Sudden pop, spark, flame, smoke, heat, or odor.

1. INFORM TEAM.

2. CALL FOR HELP.

3. CALL FOR FIRE EXTINGUISHER.

Emergency Manual V3.0 Aug. 2016

IMMEDIATE

1. Stop flow of all airway gases to patient.

2. Remove burning or flammable materials from patient

immediately for other team member to extinguish.

3. Extinguish patient fire:

• If electrical equipment burning, use only CO

fire extinguisher

(safe in wounds).

• If non-electrical, attempt to extinguish with saline and soaked

gauze.

4. Care for the patient: ventilate with room air, control bleeding,

assess injuries and vital signs.

5. Consider evacuating patient and OR if smoke or continued fire,

per local protocol.

6. Close OR doors.

7. Turn OFF external gas supply to OR.

8. Alert fire department.

For prevention of airway fires, see next page.

GO TO NEXT PAGE è

 

Emergency Manual V3.0 2016

FIRE – PATIENT continued

FOR AIRWAY FIRE: Go To Fire – Airway, event #12

PREVENTION

• Team Communication at Time Out if high risk procedure.

• Highest risk in MAC head and neck procedures

– Use nasal cannula instead of face mask, if able.

– Configure drapes to avoid O

build-up, consider active

scavenging if required.

– Use minimum O

concentration for adequate SpO

• If high O

concentration required, use an LMA or ETT.

• Allow complete drying of Alcohol skin prep solutions.

• Consider coating patient’s head hair and facial hair with water

soluble surgical lubricating jelly.

Remember: Fuel Source + Oxidizer + Spark = FIRE

END

Emergency Manual V3.0 Aug. 2016

 

Emergency Manual V3.0 2016

HEMORRHAGE

MASSIVE TRANSFUSION GUIDELINES

By Stanford Anesthesia Cognitive Aid Group

1. CALL FOR HELP.

2. CALL FOR CODE CART?

3. INFORM TEAM.

Emergency Manual V3.0 Aug. 2016

IMMEDIATE

1. Follow local protocol to order Massive Transfusion Guideline

(MTG) or equivalent.

2. Increase to 100% O

, high flow.

3. Treat hypotension with IV fluid bolus.

4. Consider Trendelenburg or elevation of patient’s legs.

5. Use vasopressor boluses (ephedrine, phenylephrine,

epinephrine) as a temporizing measure. Consider accepting low

normal blood pressure until bleeding is controlled.

6. Call for rapid infuser.

7. Establish additional IV access as needed. Consider intraosseous

if needed.

8. Ask surgeon: “Should we page a vascular surgeon or other

additional help for you?”

9. Send Type and Cross sample. TS will provide emergency

release Type O PRBC until crossmatched blood is available.

10. Maintain normothermia. Use fluid warming devices for IV and

blood products. Use forced air warmers.

11. Place arterial line as indicated.

12. Follow patient’s acid/base status by ABG as indicator of

adequate resuscitation. Monitor for hypocalcemia.

13. Place Foley Catheter when able.

14. Call for cell-saver (if non-contaminated, non-malignant case).

Replace products EARLY! until current lab data available:

• If > 1 blood volume of loss expected: give 1 unit FFP for every

1 unit PRBC. Give 1 apheresis unit of platelets (= old ‘6-

pack’) for every 6 units PRBC.

• When labs back: replace factors, platelets, fibrinogen as

indicated on next page, but do not wait if blood loss is too rapid.

GO TO NEXT PAGE è

 

Emergency Manual V3.0 2016

HEMORRHAGE

MASSIVE TRANFUSION GUIDELINES

continued

COMPONENTS

PRBC: Give for Hgb <7-10 (CAD? Rate of blood loss?) Each

unit PRBC raises Hgb ~ 1g/dL.

PLATELETS: Give for <50,000-100,000 per μL with signs of

ongoing bleeding. Each apheresis unit raises platelets

~50,000 per μL.

FRESH FROZEN PLASMA: Give for INR (PT) or PTT >1.5X

normal. Give 10-15 cc FFP per kg body weight, then

recheck labs and continue with 1:1 FFP:PRBC ratio.

CRYOPRECIPITATE: Give for fibrinogen <80-100 mg/dL.

Each 10 units of cryoprecipitate raises fibrinogen ~50

mg/dL.

VOLUMES

HCT

starting

– HCT

measured

Est. Blood Loss = EBV x

HCT

starting

Estimated Blood Volume (EBV) ~65-70 ml per kg body weight

(~4.5 L for 70 kg)

END

Emergency Manual V3.0 Aug. 2016

 

Emergency Manual V3.0 2016

HYPOTENSION

By Stanford Anesthesia Cognitive Aid Group and Geoff Lighthall, MD

1. CALL FOR HELP.

2. CALL FOR CODE CART?

3. INFORM TEAM.

IMMEDIATE

Immediate Actions:

1. Feel for pulse and check monitors. If no pulse, slow or

abnormal rhythm, Go To appropriate ACLS event.

2. Inspect surgical field for blood loss or manipulation. Consider

pausing surgery if non-bleeding cause.

3. Give IV fluid bolus. Ensure IV working.

4. Give phenylephrine or ephedrine to temporize.

• If severe refractory hypotension, consider: epinephrine 10-100

μg and/or vasopressin 1-4 units.

5. If bleeding, consider lower normal MAP until surgeon controls

source. Consider ordering blood.

6. Turn down or off anesthetic agent.

7. Consider Trendelenburg or elevation of patient’s legs.

8. Increase to 100% O

, high flow.

9. Consider terminating surgical procedure or getting surgical

help.

10. Consider code cart if severe. Monitor all vitals continuously.

11. If pulseless: alert team, start CPR, Go To PEA, event #3.

Emergency Manual V3.0 Aug. 2016

RULE OUT

First Rule out Rapidly Lethal Causes:

1. Hemorrhage ?occult (Go to Hemorrhage – MTG, event #14).

2. Vasodilators (volatile, IV anesthetics, or drips).

3. Auto-PEEP (disconnect circuit).

4. Pneumothorax (Go to Pneumothorax, event #21).

5. Anaphylaxis (Go to Anaphylaxis, event #8).

6. Cardiac event: Myocardial infarction/ischemia (Go to

Myocardial Ischemia, event #19), Low Ejection Fraction,

Systolic Anterior Motion of mitral valve, Hypertrophic Obstructive

Cardiomyopathy. TEE to assess.

7. Pneumoperitoneum or surgical manipulation.

8. IVC Compression e.g. prone, obese, pregnant, or surgical.

9. Expand Ddx using Physiologic approach on next page.

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 

Emergency Manual V3.0 2016

HYPOTENSION continued

DDX

Physiological Differential Diagnosis of Hypotension

MAP = CO x SVR CO = SV x HR

(SV components: preload, contractility, afterload)

1. Decreased Preload e.g. Auto-PEEP, hypovolemia including

hemorrhage, arrhythmias, IVC compression, embolism (air,

blood, fat, AFE), pneumothorax, pericardial tamponade,

venodilators.

2. Low SVR e.g. vasodilation (medications, neuraxial block), shock

(anaphylaxis, sepsis, spinal, neurogenic), endocrine

abnormalities.

3. Decreased Contractility e.g. medications, low EF, myocardial

ischemia, valvular disease, increased afterload, hypoxemia, local

anesthetic toxicity.

4. Low HR: including vagal stimulus.

SECONDARY

Depending on likely diagnosis, consider:

1. Treat the problem, if diagnosed. Go To relevant event if ACLS,

Anaphylaxis, Hemorrhage, Hypoxemia, Local Anesthetic Toxicity,

Myocardial Ischemia, Pneumothorax, Total Spinal Anesthesia,

Transfusion Reaction, Venous Air Embolism. For sepsis: refer to

local guidelines (IV fluids, invasive monitoring?, send lactate,

blood cultures, appropriate antibiotics).

2. Transesophageal echo if unclear cause.

3. More IV access.

4. Place arterial line.

5. Steroid for adrenal insufficiency.

(e.g. hydrocortisone 100 mg IV).

6. Send labs: ABG, Hgb, electrolytes, calcium, lactate, type & cross.

7. Foley catheter if not present. Monitor urine output.

Emergency Manual V3.0 Aug. 2016

END

 

Emergency Manual V3.0 2016

HYPOXEMIA

By Stanford Anesthesia Cognitive Aid Group and Geoff Lighthall, MD

1. CALL FOR HELP.

2. CALL FOR CODE CART?

3. INFORM TEAM.

IMMEDIATE

Immediate actions:

1. Increase to 100% O

, high flow.

2. Check gas analyzer to rule out low FiO

or high N

If concerned, Go To Oxygen Failure, event #20.

3. Check other vitals (cycle NIBP) and PIP. Feel for pulse.

4. Check for ETCO

(?extubated, disconnected, low BP).

5. Hand-ventilate: check compliance. Rule out leaks, machine

factors.

6. Listen for breath sounds (bilateral? clear?). Check position ETT.

7. Suction catheter via ETT (to clear secretions and check

obstructions).

8. Consider Pneumothorax, event #21.

9. Consider Code Cart if severe.

DDX

Differential diagnosis: See next page for details.

1. Hypoventilation.

2. Low FiO

3. V/Q mismatch or shunt.

4. Diffusion problem.

5. Increased metabolic O

demand.

Emergency Manual V3.0 Aug. 2016

SECONDARY

Depending on likely diagnosis, consider:

1. Large recruitment breaths, consider PEEP – caution if

hypotensive.

2. Bronchodilators (e.g. albuterol MDI or nebulizer).

3. Additional neuromuscular blockade if indicated.

4. Increase FRC: head up (if BP ok), desufflate abdomen.

5. Check placement of ETT:

• Fiberoptic to confirm tracheal rings, rule out mainstem

intubation or ETT obstruction.

• Ultrasound: bilateral sliding pleura are reassuring.

6. ABG and/or CXR.

7. Consider terminating procedure for refractory hypoxemia.

8. Plan for postop care: remain intubated? ICU bed?

9. Artifacts: See next page, consider after Ddx.

GO TO NEXT PAGE

 

Emergency Manual V3.0 2016

HYPOXEMIA continued

DDX

Physiological differential diagnosis of hypoxemia:

1. Low FiO

: If gas analyzer states low FiO

while on ‘100% O

’

likely have O

failure or pipeline crossover of gases. Go To

Oxygen Failure, event #20 immediately.

2. Hypoventilation: Check for signs of low minute ventilation:

• Low TV or RR. • Decreased breath sounds.

• High or low ETCO

• Patient bucking ventilator.

• Poor chest rise.

Rule out or fix equipment and patient causes:

• Circuit leak.

• Obstructed or kinked ETT.

• High PIP.

• Residual neuromuscular blockade.

• Patient breathing asynchronously with ventilator.

Postoperative respiratory failure common causes: residual

nmb, opioid, anesthetic, laryngospasm (sudden), bronchospasm,

pulmonary edema, high spinal, pain.

3. V/Q Mismatch or Shunt: A-a Gradient common causes:

• Mainstem intubation. • Bronchospasm

(+?Anaphylaxis).

• Atelectasis. • Mucus plug.

• Aspiration. • Pleural effusion.

CONSIDER rare but critical:

• Pneumothorax.

• Hypotension – any cause of poor perfusion.

• Embolus – air, blood, fat, AFE.

4. Diffusion abnormality: Usually chronic lung disease.

5. Methemoglobinemia (O

Sat ~85%), COHgb (O

Sat often

normal). If suspect, send for co-oximetry.

6. Increased metabolic O

demand: MH, thyrotoxicosis, sepsis,

hyperthermia, neuroleptic malignant syndrome.

7. Artifacts: finally, confirm by ABG. e.g. poor waveform (probe

malposition, cold extremity, light interference, cautery), dyes

(methylene blue, indigo carmine, blue nail polish).

Emergency Manual V3.0 Aug. 2016

END

 

Emergency Manual V3.0 2016

LOCAL ANESTHETIC TOXICITY

By Stanford Anesthesia Cognitive Aid Group

SIGNS

1. Symptoms:

Tinnitus, metallic taste,

or circumoral

numbness.

2. Altered mental status.

3. Seizures.

4. Hypotension.

5. Bradycardia.

6. Ventricular arrhythmias.

7. Cardiovascular collapse.

1. CALL FOR HELP.

2. Alert possible CPB.

3. CALL FOR CODE CART.

4. INFORM TEAM.

Emergency Manual V3.0 Aug. 2016

TREATMENT

1. Call for Intralipid kit.

2. If pulseless, start CPR and give <1 mcg/kg epinephrine.

3. Avoid vasopressin.

4. Stop local anesthetic injection and/or infusion.

5. Establish airway – ensure adequate ventilation and

oxygenation. Consider endotracheal intubation.

6. Treat seizure activity with benzodiazepines.

7. If signs persist or patient unstable: Rapidly give 1.5 mL/kg

bolus of 20% Intralipid IV (70 kg adult gets 105 mL fast)

then start infusion at 0.25 mL/kg/min. May repeat loading dose

(max 3 total doses). May increase infusion rate (max 0.5

mL/kg/min).

8. Monitor for hemodynamic instability – treat hypotension (see

next page for details).

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Emergency Manual V3.0 2016

LOCAL ANESTHETIC TOXICITY

continued

SECONDARY

1. Variable arrhythmias: Go to appropriate ACLS event with the

following modifications per ASRA Practice Advisory:

• CONSIDER reducing Epinephrine doses <1 mcg/kg IV.

• AVOID: Vasopressin, calcium channel blockers, beta

blockers, and local anesthetics.

2. If refractory to treatment, alert personnel for potential

cardiopulmonary bypass.

3. May require prolonged resuscitation.

4. Monitor the patient post event in ICU.

For latest recommendations, see ASRA website

(http://www.asra.com).

CPR:

1. 100–120 compressions/minute; ≥ 2” deep.

Allow complete chest recoil.

2. Minimize breaks in CPR.

3. Rotate Compressors q2 min.

Assess CPR quality, improve IF:

• ETCO

< 10 mmHg.

• Arterial line Diastolic < 20 mmHg.

END

Emergency Manual V3.0 Aug. 2016

 

Emergency Manual V3.0 2016

MALIGNANT HYPERTHERMIA

By Stanford Anesthesia Cognitive Aid Group and Henry Rosenberg, MD

SIGNS

EARLY: May be LATER

1. Increased ETCO

. 1. Hyperthermia.

2. Tachycardia. 2. Muscle rigidity.

3. Tachypnea. 3. Myoglobinuria.

4. Mixed Acidosis (ABG). 4. Arrhythmias.

5. Masseter spasm/trismus. 5. Cardiac Arrest.

6. Sudden cardiac arrest in young

person due to hyperkalemia.

1. CALL FOR HELP.

2. CALL FOR MH CART.

3. INFORM TEAM.

4. START PREPARING DANTROLENE or RYANODEX!

DDX

• Light anesthesia. • Thyroid Storm.

• Hypoventilation. • Pheochromocytoma.

• Insufflation of CO

. • Neuroleptic Malignant Syndrome (NMS).

• Over-heating (external). • Serotonin Syndrome.

• Hypoxemia.

Emergency Manual V3.0 Aug. 2016

TREATMENT

1. Discontinue anesthetic triggers (volatiles and succinylcholine).

Do NOT change machine or circuit.

2. Increase to 100% O

, high flow 10 L/min.

3. Halt procedure if possible. If emergent, continue with non-

triggering anesthetic.

4. Increase minute ventilation (but avoid air trapping).

5. Assign several people to prepare 2.5 mg/kg IV Dantrolene or

Ryanodex bolus:

• Dantrolene: Dilute each 20 mg Dantrolene vial in 60 mL

preservative-free sterile water (for 70 kg person give 175 mg

so prepare 9 vials of 20 mg Dantrolene each as above).

• Ryanodex (new formulation of Dantrolene): Dilute 250 mg

Ryanodex vial in 5 mL preservative-free sterile water (for 70

kg person give 175 mg).

6. Rapidly give Dantrolene or Ryanodex. Continue giving until

patient stable (may need >10 mg/kg, call MHAUS 800-644-9737 for

advice).

7. For metabolic acidosis, give sodium bicarbonate 1-2 mEq/kg.

MH Treatment continued on next page.

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Emergency Manual V3.0 2016

MALIGNANT

HYPERTHERM

Emergency Manual V3.1 2016

MALIGNANT HYPERTHERMIA

continued

TREATMENT

8. Hyperkalemia – or suspect from EKG, treat with:

• Calcium chloride 10 mg/kg IV; Max dose 2000 mg or

Calcium gluconate 30 mg/kg IV, Max dose 3000 mg.

• D50 1 Amp IV (25 g or 50 ml Dextrose) + Regular Insulin

10 units IV (monitor glucose).

• Sodium Bicarbonate 1-2 mEq/kg, Max dose 50 mEq.

9. Arrhythmias are usually secondary to Hyperkalemia. Treat as

needed except avoid calcium channel blockers. Go to ACLS

events as relevant and return.

10. Actively cool patient with ice packs, lavage if open abdomen.

Stop cooling at 38°C.

11. Send labs for ABG, Potassium, CK, urine myoglobin, coagulation

studies, lactate.

12. Place Foley catheter. Monitor UO. Goal 1-2 mL/kg per hour.

Can give IV fluid and diuretics.

13. Consider alkalinizing urine if CK or urine myoglobin elevated

(Sodium Bicarbonate 1mEq/kg/hour).

14. Arrange ICU bed. Mechanical ventilation usually required.

15. Continue Dantrolene or Ryanodex: 1 mg/kg every 4-6 hours or

0.25 mg/kg/hr infusion for at least 24 hours (25 % of MH events

relapse). Observe patient in ICU for at least 24 hours.

16. Call MH hotline (below)for any suspected case with any

questions.

Contact the Malignant Hyperthermia Association of the

United States (MHAUS hotline) at any time for consultation

if MH is suspected:

1-800-MH-HYPER (1-800-644-9737)

or see suggestions online at http://www.mhaus.org

Emergency Manual V3.1 Oct.

2016

END

 

MALIGNANT

HYPERTHERM

MYOCARDIAL ISCHEMIA

By Stanford Anesthesia Cognitive Aid Group

SIGNS

Suspect myocardial ischemia if:

1. Depression or elevation of ST segment.

2. Arrhythmias: conduction abnormalities, unexplained

tachycardia, bradycardia, or hypotension.

3. Regional wall motion abnormalities or new/worse mitral

regurgitation on TEE/TTE.

4. In awake patient: chest pain, etc.

1. CALL FOR HELP.

2. CALL FOR CODE CART.

3. INFORM TEAM.

TREATMENT

1. If hypoxemic, increase to 100% O

, high flow.

2. Verify ischemia (expanded monitor view vs 12-lead EKG).

3. Treat hypotension or hypertension.

4. Be prepared for Arrhythmias and have Code Cart at bedside.

Consider applying pads.

5. Beta-blocker to slow heart rate. Hold for bradycardia or

hypotension.

6. Discuss with surgeon: aspirin 160-325mg PR, PO, NG.

7. Consider STEMI team or consult Cardiology – stat. Discuss

among cardiology, surgery, anesthesia:

• Heparin +/- Clopidogrel.

8. Treat pain with narcotics (fentanyl or morphine).

9. Consider nitroglycerin infusion (hold until hypotension treated).

10 Place arterial line and send Labs: ABG, CBC, Troponin.

11. If Anemic, treat with packed red blood cells.

12. Consider TTE or TEE Echocardiography for monitoring volume

status and regional wall motion abnormalities.

13. Consider central venous access.

14. If hemodynamically unstable, consider Intra-Aortic Balloon

Pump.

Emergency Manual V3.0 Aug. 2016

END

 

Emergency Manual V3.0 2016

OXYGEN FAILURE

CROSS OVER / PIPELINE FAILURE

By Stanford Anesthesia Cognitive Aid Group and Seshadri C. Mudumbai, MD

SIGNS

• Hear O

failure alarm. OR • Inappropriately low FiO

value

on gas analyzer.

IMMEDIATE

Immediate Actions:

1. Disconnect the patient from the machine and ventilate with

an Ambu

bag on Room Air. Do not connect the patient to

auxiliary flowmeter on machine – comes from SAME central

source!

2. Open O

tank on back of anesthesia machine (check not

empty) and disconnect pipeline oxygen to force flow from tank

into circuit

Alternative: Obtain full E cylinder of O

with a regulator.

Ventilate with Ambu

bag or Jackson Rees circuit attached to

new O

tank.

3. Connect gas sampling adaptor to allow monitoring of

respiratory gases:

Is the patient receiving 100% oxygen?

4. Maintain anesthesia (if necessary) with IV drugs

1. CALL FOR HELP.

2. CALL FOR CODE CART?

3. INFORM TEAM.

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SECONDARY

1. Reduce O

flow rates to minimum needed to conserve oxygen.

2. Obtain extra backup sources of O

3. When patient more stable, contact Bioengineers to alert them to

problem and enlist help with machine diagnosis while you focus

on patient.

4. Inform OR leadership, ICU, hospital of potential large-scale O

problem.

5. Discuss with surgeon implications of O

failure for this patient’s

management and OR schedule.

Emergency Manual V3.0 Aug. 2016

END

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Emergency Manual V3.0 2016

PNEUMOTHORAX

By Stanford Anesthesia Cognitive Aid Group

SIGNS

1. Increased peak inspiratory pressures.

2. Tachycardia.

3. Hypotension.

4. Hypoxemia.

5. Decreased or asymmetric breath sounds.

6. Hyperresonance of chest to percussion.

7. Tracheal deviation (late sign).

8. Increased JVD/CVP.

9. Have high index of suspicion for pneumothorax in trauma

patients and COPD patients.

1. CALL FOR HELP.

2. CALL FOR CODE CART?

3. INFORM TEAM.

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TREATMENT

1. Increase to 100% O

, high flow.

2. Rule out mainstem intubation.

3. Consider Ultrasound or stat CXR.

4. Do Not Delay Treatment If Hemodynamically Unstable.

5. Place 14 or 16 gauge needle mid clavicular line 2nd

intercostal space on affected side, may hear a whoosh of air if

under tension.

6. Immediately follow up needle decompression with thoracostomy

(chest tube).

Emergency Manual V3.0 Aug. 2016

END

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Emergency Manual V3.0 2016

POWER FAILURE

By Stanford Anesthesia Cognitive Aid Group

IMMEDIATE LIFESAVING ACTIONS:

1. Get additional light sources:

• Laryngoscopes, cell phones, flashlights, etc.

2. Open doors and shades to let in ambient light.

3. Confirm ventilator is working and if not,

ventilate patient with Ambu

bag and switch

to TIVA.

4. If monitors fail, check pulse and manual blood

pressure.

5. Request Transport Monitor or defibrillator

monitor.

6. Confirm adequate backup O

supply:

• Power failure may affect oxygen supply or

alarms.

7. Check extent of power failure:

• Call bio-med or engineering.

• Is the problem in one OR, all ORs, or hospital-

wide?

• If only in your OR, check if circuit breaker has

been tripped.

Emergency Manual V3.0 Aug. 2016

END

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Emergency Manual V3.0 2016

TOTAL SPINAL ANESTHESIA

By Stanford Anesthesia Cognitive Aid Group

SIGNS

AFTER NEURAXIAL ANESTHESIA BLOCK:

1. Unexpected rapid rise in sensory blockade.

2. Numbness or weakness in upper extremities (check hand

grip).

3. Dyspnea.

4. Bradycardia.

5. Hypotension (or nausea/vomiting).

6. Loss of consciousness.

7. Apnea.

8. Cardiac arrest.

1. CALL FOR HELP.

2. CALL FOR CODE CART.

3. INFORM TEAM.

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TREATMENT

1. If Cardiac Arrest: Start CPR, immediate epinephrine, Go To

appropriate ACLS event.

2. Support ventilation and intubate if necessary.

3. Treat significant bradycardia or hypotension with immediate

epinephrine (start 10-100 μg, increase as needed). If mild

bradycardia, consider atropine (0.5-1 mg), but progress quickly

to epinephrine if needed.

4. Give IV fluid bolus.

5. If parturient: Left uterine displacement, call OB and

neonatology, prepare for possible emergent C-section, monitor

fetal heart rate.

Emergency Manual V3.0 Aug. 2016

END

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Emergency Manual V3.0 2016

TRANSFUSION REACTIONS

By Stanford Anesthesia Cognitive Aid Group

SIGNS

Hemolytic Reaction

1. Fever.

2. Back/flank pain.

3. Tachycardia.

4. Tachypnea.

5. Hypotension.

6. Dark urine.

7. Oozing – DIC?

Febrile

1. Fever.

2. Chills/rigors.

3. Headache.

4. Vomiting.

Anaphylactic

1. Hypotension.

2. Urticaria/hives.

3. Wheezing.

4. Tachycardia.

1. CALL FOR HELP.

2. CALL FOR CODE CART?

3. INFORM TEAM.

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TREATMENT

1. Stop the transfusion.

2. Support blood pressure with IV fluids and vasoactive medications

if needed.

3. Retain blood product bag and notify Transfusion Service.

Additional patient samples will need to be drawn.

4. Consult Transfusion Medicine MD if advice needed.

5. Consider TRALI or volume overload if evidence of lung injury

(hypoxemia, pulmonary edema). May require post-operative

ventilation.

Hemolytic Reaction

• Maintain urine output

– IV fluids, diuretics,

renal dose dopamine.

• Monitor for signs of

DIC.

Febrile

• Treat with anti-

pyretics.

• Rule out

hemolysis.

• Rule out

bacterial

contamination.

Anaphylactic

• Epinephrine

infusion.

• Give

antihistamines.

• Go To

Anaphylaxis

event #8.

Emergency Manual V3.1 Oct. 2016

END

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Emergency Manual V3.0 2016

VENOUS AIR EMBOLUS

By Stanford Anesthesia Cognitive Aid Group

SIGNS

OBSERVE SUDDEN:

1. Air on TEE or change in Doppler tone (if monitoring).

2. Decrease in ETCO

3. Decrease in BP.

4. Decrease in SpO

5. Rise in CVP.

6. Onset of dyspnea and respiratory distress or cough in

awake patient.

1. CALL FOR HELP.

2. CALL FOR CODE CART?

3. INFORM TEAM.

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TREATMENT

1. Increase to 100% O

, high flow.

2. Flood surgical field with saline.

3. Place surgical site below heart (if able).

4. Aspirate air from the central line if present.

5. Give rapid fluid bolus to increase CVP.

6. Turn down or off volatile anesthetic.

7. Give epinephrine (start 10-100 μg) to maintain cardiac output.

8. Start CPR if BP catastrophically low.

9. Consider TTE or TEE Echocardiography to assess air & RV

function.

10. Consider left lateral decubitus.

11. If severe, terminate procedure if able.

Emergency Manual V3.1 Oct. 2016

END

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Emergency Manual V3.0 2016

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Place holder

to insert local

emergency

phone numbers

Emergency Manual V3.0 2016